Facial Paralysis House Brackmann Scale
Assesses the degree of facial paralysis induced by facial nerve damage.
In the text below the calculator you can find more information about the scale and about facial paralysis.
The House Brackmann scale is a standardized facial nerve grading system that evaluates how severe facial paralysis is, based on gross function at rest and in effort and on motion function in the area of the forehead, eyes and mouth.
The paralysis grading system was described in 1958 and is addressed to patients suffering from conditions that involve damage to the facial nerve, such as unilateral Bell palsy, the Ramsay Hunt syndrome or Lyme disease.
There are 6 grades in this scale, that are assigned Roman numbers from I to VI, I indicating normal function while VI is suggestive of complete paralysis.
During the clinical assessment, measurements of facial modifications are taken and depending on the result, are associated with one of the 6 degrees on the House Brackmann scale.
This method has been criticized for not correlating entirely with best or worst function in the studied domains.
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The grading system explained
This is a standardized assessment to be used in patients with facial paralysis. It is basically a facial nerve grading system that rates gross function at effort and at rest and motion function of the forehead area, the eyes and mouth area.
The scale was created in 1985, by Dr John W. House and Dr Derald E. Brackmann, otolaryngologists from California.
There are 6 grades in this scale, that are assigned Roman numbers from I to VI, I indicating normal function while VI is suggestive of complete paralysis.
The association between the five items in the above scale and the House Brackmann grading is presented in the following table:
| Grade I - Normal | Normal facial function in all areas. |
| Grade II - Slight Dysfunction | Gross: slight weakness noticeable on close inspection; may have very slight synkinesis; At rest: normal symmetry and tone; Motion: Forehead - moderate to good function; Eyes - complete closure with minimum effort; Mouth - slight asymmetry. |
| Grade III - Moderate Dysfunction | Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis, contracture, and/or hemi-facial spasm; At rest: normal symmetry and tone; Motion: Forehead - slight to moderate movement; Eyes - complete closure with effort; Mouth - slightly weak with maximum effort. |
| Grade IV - Moderate Severe Dysfunction | Gross: obvious weakness and/or disfiguring asymmetry; At rest: normal symmetry and tone; Motion: Forehead - none; Eyes - incomplete closure; Mouth - asymmetric with maximum effort. |
| Grade V - Severe Dysfunction | Gross: only barely perceptible motion; At rest: asymmetry; Motion: Forehead - none; Eyes - incomplete closure; Mouth - slight movement; |
| Grade VI - Total Paralysis | No movement. |
The House Brackmann scale has also been criticized for insufficient correlation with best or worst function in the studied domains.
The highest correlation of the overall grading is with the regional scoring of the eye at 61% while the lowest is with the forehead region at 18%.
The clinical assessment also involves taking measurements of the:
■ Upwards (superior) movement of the mid-portion of the top of the eyebrow;
■ Outwards (lateral) movement of the angle of the mouth.
In each reference region 1 point is awarded for each 0.25 cm of movement up to 1 cm. The result is then provided as a number of points out of 8 (the maximum obtainable).
It is associated with one of the six grades during initial assessment and can also be used in the monitoring of recovery after Bell palsy.
| Grade | Description | Measurement | Function % | Estimated Function % |
| I | Normal | 8/8 | 100 | 100 |
| II | Slight | 7/8 | 76 - 99 | 80 |
| III | Moderate | 5/8 - 6/8 | 51 - 75 | 60 |
| IV | Moderately Severe | 3/8 - 4/8 | 26 - 50 | 40 |
| V | Severe | 1/8 - 2/8 | 1 - 25 | 20 |
| VI | Total | 0/8 | 0 | 0 |
Facial paralysis guidelines
The function of facial muscles is essential in mastication, speech and emotion expression, therefore facial nerve injury, either complete or partial is of important concern because it can result in facial paralysis.
The severity of symptoms depends on individual facial anatomy, age aspects and the extent of damage to nerve № VII.
These are the most common causes of facial paralysis:
■ Unilateral Bell palsy;
■ Ramsay Hunt syndrome;
■ Lyme disease;
■ Viral etiology (e.g. herpes simplex virus);
■ Malignancy;
■ Trauma;
■ Iatrogenic, or idiopathic etiology.
A severe degree of impairment can be recognized even at rest whilst less severe degrees may require specialist examination.
The symptoms that are consistent with impaired function in the facial nerve are summarized in the table below:
| Movement abnormalities | Abnormal brow position |
| Mid-facial asymmetries | Eyelid closure issues |
| Lower lip asymmetry | Poor oral function |
| Inability to smile | No neuropathic sensation of pain |
When intervention takes place early, there are higher chances of recovery of function, either spontaneous or after corrective surgery.
Original source
House JW, Brackmann DE. (1985) Facial nerve grading system. Otolaryngol Head Neck Surg. 1985; 93(2):146-7.
Other references
1. Yen TL, Driscoll CL, Lalwani AK. Significance of House-Brackmann facial nerve grading global score in the setting of differential facial nerve function. Otol Neurotol. 2003; 24(1):118-22.
2. Kang TS, Vrabec JT, Giddings N, Terris DJ. Facial nerve grading systems (1985-2002): beyond the House-Brackmann scale. Otol Neurotol. 2002; 23(5):767-71.
3. Danner CJ. Facial nerve paralysis. Otolaryngol Clin North Am. 2008; 41(3):619-32.
Specialty: Neurology
System: Nervous
Objective: Evaluation
Type: Scale
No. Of Items: 5
Year Of Study: 1985
Article By: Denise Nedea
Published On: June 13, 2017 · 10:10 AM
Last Checked: June 13, 2017
Next Review: June 13, 2023